ABSTRACT To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36 months postrandomization and to test whether these outcomes were predicted by the randomly assigned treatments and subsequent self-selected prescribed medications.
Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.
Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Children randomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02). Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use. By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use.
Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence.

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Delinquent Behavior and Emerging Substance Usein the MTA at 36 Months: Prevalence, Course,and Treatment EffectsBROOKE S.G. MOLINA, PH.D., KATE FLORY, PH.D., STEPHEN P. HINSHAW, PH.D.,ANDREW R. GREINER, B.S., L. EUGENE ARNOLD, M.D., JAMES M. SWANSON, PH.D.,LILY HECHTMAN, M.D., PETER S. JENSEN, M.D., BENEDETTO VITIELLO, M.D.,BETSY HOZA, PH.D., WILLIAM E. PELHAM, PH.D., GLEN R. ELLIOTT, PH.D., M.D.,KAREN C. WELLS, PH.D., HOWARD B. ABIKOFF, PH.D., ROBERT D. GIBBONS, PH.D.,SUE MARCUS, PH.D., C. KEITH CONNERS, PH.D., JEFFERY N. EPSTEIN, PH.D.,LAURENCE L. GREENHILL, M.D., JOHN S. MARCH, M.D., M.P.H.,JEFFREY H. NEWCORN, M.D., JOANNE B. SEVERE, M.S., AND TIMOTHY WIGAL, PH.D.ABSTRACTObjective: To compare delinquent behavior and early substance use between the children in the Multimodal TreatmentStudy of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36months postrandomization and to test whether these outcomes were predicted by the randomly assigned treatments andsubsequent self-selected prescribed medications. Method: Most MTA children were 11 to 13 years old by 36 months.Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.Results: Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g.,27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Childrenrandomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02).Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquencyseriousness or substance use. By 24 and 36 months, more days of prescribed medication were associated with moreserious delinquency but not substance use. Conclusions: Cause-and-effect relationships between medication treatmentand delinquency are unclear; the absence of associations between medication treatment and substance use needs to bere-evaluated at older ages. Findingsunderscoretheneedforcontinuousmonitoringoftheseoutcomesaschildrenwithattention-deficit/hyperactivity disorder enter adolescence. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(8):1027Y1039. Key Words:attention-deficit/hyperactivitydisorder,treatment,multimodal,medication,substanceuse,delinquency.Accepted January 4, 2007.Please see end of text for author affiliations.Theworkreportedwassupportedbycooperativeagreementgrantsandcontractsfrom the National Institute of Mental Health to the following: University ofCalifornia, Berkeley: U01 MH50461 and N01MH12009; Duke University:U01 MH50477 and N01MH12012; University of California, Irvine: U01MH50440 and N01MH 12011; Research Foundation for Mental Hygiene(New York State Psychiatric Institute/Columbia University): U01 MH50467andN01MH12007;LongIsland-JewishMedicalCenterU01MH50453;NewYork University: N01MH 12004; University of Pittsburgh: U01 MH50467and N01 MH 12010; and McGill University N01MH12008.- The Office ofSpecial Education Programs of the U.S. Department of Education, the Office ofJuvenile Justice and Delinquency Prevention of the Justice Department, and theNational Institute on Drug Abuse also participated in funding.AppreciationisextendedtoDr.PatrickCurran,UniversityofNorthCarolina,Chapel Hill, and Dr. Linda Muthe ´n, Muthe ´n & Muthe ´n, Los Angeles, for theirguidance regarding the technical aspects of the growth modeling used in thisarticle, and to Drs. Magda Stouthamer-Loeber, Rolf Loeber, and Steven Lee fortheir assistance regarding the delinquency coding strategies used herein.The opinions and assertions contained in this report are the private views ofthe authors and are not to be construed as official or as reflecting the views of theNational Institute of Mental Health, the National Institutes of Health, or theDepartment of Health and Human Services.Correspondence to Dr. Brooke Molina, Department of Psychiatry, Universityof Pittsburgh School of Medicine, 3811 O_Hara Street, Pittsburgh, PA 15213;e-mail: molinab@upmc.edu.0890-8567/07/4608-1027?2007 by the American Academy of Childand Adolescent Psychiatry.DOI: 10.1097/chi.0b013e3180686d96S P E C I A L S E C T I O N1027J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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Childhood attention-deficit/hyperactivity disorder(ADHD) is associated with the later development ofserious conduct problems (Hinshaw et al., 1993;Loeber et al., 1995) and substance use/substance usedisorder (Gittelman et al., 1985; Molina and Pelham,2003). Not all children with ADHD develop theseproblems, and the specificity of early ADHD as a riskfactor is uncertain, given that co-occurring externalizingbehavior problems often emerge as independentpredictors (Lahey et al., 2000; Lee and Hinshaw,2004; Lilienfeld and Waldman, 1990), but childrenwith ADHD are nonetheless at risk. The children in theMultimodal Treatment Study of Children WithADHD (MTA) were 7.0 to 9.9 years old at studyentry, causing them to be well below the age ofmaximum risk of these outcomes at the end oftreatment 14 months later. By the 36-month assess-ment, however, 90% of the MTA children werebetween 11 and 13 years of age, on the threshold ofadolescence when antisocial behaviors escalate (Loeberet al., 1991) and initiation of Bgateway[ drug use occurs(Kandel and Yamaguchi, 2002). Thus, our aims were todetermine the extent of these developmentally andclinically salient behaviors at the 36-month assessment,their co-occurrence, and their course as a function ofrandomly assigned treatment and subsequent self-selected, prescription medication treatment.A number of reports have described the results of theMTA at the 14- and 24-month assessments (Owenset al., 2003; Swanson et al., 2001; The MTACooperative Group, 1999a,b, 2004a,b). The compa-nion article in this issue by Jensen et al. extends findingsfor primary outcome measures to the 36-monthassessment. Across these reports, externalizing behaviorsbeyond ADHD symptoms were examined as symptomsof oppositional defiant disorder (ODD; The MTACooperative Group, 1999a, 2004a,b), ODD andADHD symptoms aggregated (Swanson et al., 2001),a single measure composite indexing a range ofimpairments and symptoms beyond those of ADHDand ODD (Conners et al., 2001), or a composite ofODD and conduct disorder (CD) diagnoses (Arnoldet al., 2005; Jensen et al., 2001). Such amalgamationwas practical given the relatively low base rates of CD atbaseline (14.3%) and immediate posttreatment (6.5%).However, given the age of the sample and theimportance of examining conduct disordered anddelinquent behaviors as outcomes in their own right,it is now time to appraise effects on delinquency-relatedbehaviors per se.A method for classification of delinquency serious-ness was introduced by Wolfgang et al. (1985) andsubsequently adapted for use with the boys in thePittsburgh Youth Study (Loeber et al., 1991), alongitudinal study of urban boys in Pittsburgh. Thisclinically intuitive scoring algorithm classifies eachchild_s delinquent behavior along a continuum ofseverity from mild (e.g., stealing an item worth less than$5) to serious (e.g., attacking to seriously hurt or kill).This method, which makes use of information acrossmeasures and reporters, also allows Bdynamicclassification[ of offenders such that differences acrossmeasurement occasions may be modeled to captureworsening, improving, or static clinical profiles. Thus,in longitudinal studies such as the MTA that featuremultiple-method, multiple-reporter data sets, thisstrategy for studying delinquency provides a parsimo-nious and clinically relevant measure with demon-strated predictive utility and concurrent validity(Loeber et al., 1991). One study of adolescent boyswith and without childhood ADHD used this methodand found, in addition to significantly higher delin-quency severity scores for the probands, increased riskof delinquency severity among boys with childhoodhistories of covert (e.g., stealing, property destruction)antisocialbehavior(LeeandHinshaw,2004).Inadditiontoillustratingthemethod_spotentialutility,thisfindinghighlights the importance of measuring behaviors ofwhich adult reporters may be relatively unaware.A related concern for children with ADHD is theirpotential for substance use, abuse, and dependence,especially as influenced by their treatment withstimulant medications (see Wilens et al., 2003 for areview). An often-cited study (Biederman et al., 1999)reported that medication for ADHD is associated withdecreased risk of substance use disorder, but replicationis crucial for a number of reasons, including the smallsize (56 medicated vs. 19 unmedicated adolescents) andlarge group differences at baseline in variables thatcontribute to substance use (age, lifetime risk of CD,previous substance use disorder). At 36 months theMTA children were still below the age of high risk ofsubstance abuse or dependence, but initial use ofalcohol,tobacco, andoccasionally illicit drugs can beginat this age. Although adolescent experimentation withsubstances legal for adult use may be normative,MOLINA ET AL.1028J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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substance use at an atypically young age is associatedwith later substance-related problems (e.g., Grant andDawson, 1997). Thus, in addition to comparing earlysubstance use between the MTA and our localnormative comparison group (LNCG), an importantclinical question is whether treatment history, eitherrandomly assigned or self-selected, is associated withemerging substance use in early adolescence.Using data from the MTA through 36 months(including the 24-month assessment), we compared theextent of serious delinquent behavior and emergingsubstance use (not abuse or dependence) for thechildren in the MTA compared to our LNCG, whichwas recruited at the 24-month assessment. We alsoexamined whether our initial, randomly assignedtreatments and subsequent self-selected prescriptionmedication use were associated with an increase ordecrease in delinquency over time, with participants_levels of delinquency, and with substance use at the24- and 36-month assessments.METHODParticipantsParticipants were 579 MTA children with DSM-IV ADHDCombined type and an additional 289 LNCG children (describedbelow). Each of 6 sites randomized 96 to 98 children to one of fourtreatment groups: intensive multicomponent behavior therapy(Beh), intensive medication management (MedMgt), the combina-tion of Beh and MedMgt (Comb), or referral to usual communitycare (CC). At baseline (pretreatment), participants were 7.0Y9.9years of age (mean 8.5 years, SD 0.8). The MTA recruitmentstrategy, procedures for diagnosing ADHD, treatment specifics, andsample demographics have been described elsewhere (Arnold et al.,1997; Greenhill et al., 1996, 2001; Hinshaw et al., 1997; The MTACooperative Group, 1999a,b, 2004a,b; Wells et al., 2000).Participants were reassessed at completion of the 14-monthtreatment phase (mean age [SD] 9.57 [0.84] years; range 8Y12years), at 24 months postrandomization (mean age [SD] 10.43[0.86] years; range 9Y12 years), and at 36 months postrandomiza-tion (mean age [SD] 11.72 [0.92] years; range 10Y14 years).Participantretentionratewas97%at14months,93%at24months,and 84% at 36 months. There were no significant differences inbaseline characteristics between participating subjects and those whohad withdrawn from the study at any of these assessments (see thecompanion article by Jensen et al. in this issue).The recruitment strategy for LNCG was designed to reflect thelocal population from which the MTA sample was drawn. TheLNCG children were randomly selected from the same schools andgrades and in the same gender proportions as the MTA children.ADHD diagnosis was neither an inclusion nor exclusion for theLNCG, but the assessment battery included the DiagnosticInterview Schedule for Children IV (Shaffer et al., 2000), whichafforded examination of DSM-IV diagnoses. Otherwise the LNCGhad the same entry criteria as the MTA except for age. Because theLNCG was not recruited until 2 years after the MTA subjects, wehave data starting at 24 months rather than baseline for this group.At this time, for the LNCG, mean age (SD) was 10.37 (1.08) years(range 8Y13 years); at 36 months, mean age (SD) was 11.47 (1.15)years (range 9Y15 years). The age range was broader in the LNCGsample because they were selected by grade, not age, but as with theMTA probands, most LNCG children were 9Y12 years at 24months (94%) and 10Y13 at 36 months (94%). Mean age did notdiffer at 24 months (t [df = 811] = 1.04; p = .36), but the MTAchildren were slightly older than the LNCG children at 36 months(t [df = 758] = 3.19; p = .001), due to more difficulty and delay inarranging assessment visits relative to the LNCG. Therefore, wecontrolled for age in the 36-month MTA-LNCG group compar-isons. The percentage of females was similar in the LNCG (18.7%,n = 54/289) and MTA samples (19.7%, n = 114/579, x21= 0.13,not significant). The percentage retained at 36 months was 94.5%(n = 273).MeasuresDelinquency Seriousness Classification. Data for delinquencyseriousness emanated from two parent report measures, theDiagnostic Interview Schedule for Children IV-CD Module andthe Parent DSM-IV Aggression and Conduct Disorder Rating Scale(American Psychiatric Association, 1994), and two self-reportmeasures, the Self-Reported Antisocial Behavior questionnaire(Loeber et al., 1989) through the 24-month assessment and theSelf-Reported Delinquency questionnaire (Elliott et al., 1985) at the36-month assessment. Using all of the available data and proceduresdeveloped by Wolfgang and colleagues (1985) and others (e.g., Leeand Hinshaw, 2004; Loeber et al., 1991, 1998), participants wereassigned a delinquency classification code at each assessment point(baseline and 14, 24, and 36 months). Items contributing to eachcode were selected to replicate the coding scheme used in thePittsburgh Youth Study (Loeber et al., 1991, 1998). Delinquencywas coded along an ordinal scale based on the most serious actcommitted during the past 6 months: 0 = no delinquency; 1 =minor delinquency only at home (e.g., theft of less than $5 orvandalism); 2 = minor delinquency outside of the home (e.g.,vandalism, cheating someone, shoplifting less than $5); 3 =moderately serious delinquency (e.g., vandalism, theft of $5 ormore, weapon carrying); 4 = serious delinquency (e.g., breaking andentering, drug selling, attacking someone with the intent toseriously hurt or kill, rape); and 5 = engagement in two or moredifferent level 4 offenses. Because only a small number of MTAchildren were coded 5 (n = 14 at baseline, n = 4Y5 between 14 and36 months), we grouped codes 4 and 5 for data analyses, making afive-level ordinal scale of 0 to 4.Substance Use Outcomes. Substance use was assessed at 24 and 36months using a child-reported substance use questionnaire (Molinaand Pelham, 2003) adapted for the MTA. The measure includeditems for lifetime and current (past 6 months) use of licit substances(alcohol, cigarettes, chewing tobacco) and illicit drugs (marijuanaand other street drugs). Also included were items for inappropriateor nonprescribed use of medications, including stimulants. Themeasure was modeled after similar substance use measures inlongitudinal or national survey studies of alcohol and other drug use(Donovan, 1994; Jessor et al., 1989; National Household Survey onDrug Abuse, 1992) that also rely on confidential youth self-report asthe best source of such data (Winters and Fahnhorst, 2005). As inother studies of young adolescents (Chilcoat and Breslau, 1999),MTA DELINQUENCY AND SUBSTANCE USE1029J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

assessment points (recall that the LNCG began at the24-month assessment). Following established practice(Lee and Hinshaw, 2004), the right side of Table 1shows the percentages of children with either moderate(code 3) or serious (codes 4Y5) delinquency at each ofthe assessments, separately for the MTA and LNCGchildren.Across all of the assessments, most of the MTAchildren were not engaging in high levels of delin-quency. Less than one third of the MTA sample wascharacterized by moderate to serious delinquency. Ageneral trend was visible such that moderate to seriousdelinquency decreased from baseline to the 24-monthassessment (10 months after treatment ended) but thenincreased by the 36-month assessment. Behaviors mostcommonly endorsed by MTA children or their parentsand that resulted in a code of 3+ included stealingwithout confrontation of the victim (e.g., shoplifting,stealing from someone_s desk or locker); hitting thatresulted in the victim being cut, bleeding, beingknocked unconscious, or being hospitalized; carryinga hidden weapon such as a knife or gun; and using aweapon such as a bat or brick that caused serious harm.As expected with the ages of the children in this study,the most egregious delinquent acts, such as forcedsexual behavior, were rarely or never endorsed.More MTA than LNCG youth had engaged inmoderate to serious levels of delinquency by the 24- and36-month assessments (right side of Table 1). Thesegroup differences were also evident when examinedseparately by sex (Table 2).There was appreciable overlap with CD diagnosis,but a large number of children were coded asdelinquent at baseline without having been diagnosedwith CD at baseline: specifically, 66.7% (56/84) ofchildren with CD had moderate to serious delinquency,but only 32.9% (56/170) of children with moderate toserious delinquency had CD (x21= 59.82, p = .000, n =579). This pattern was also evident for CD diagnosisand moderate to serious delinquency assessed at the 36-month follow-up: 80.6% (25/31) and 18.9% (25/132),respectively (x21= 41.07, p = .000, n = 480. Thus,although CD diagnosis was strongly and significantlycorrelated with delinquency and baseline CD predictedmoderate to serious delinquency at 36 months (x21=26.16, p = .000, odds ratio [OR] = 3.83, n = 487), mostchildren with delinquent behavior were not diagnosedwith CD. This finding probably emanates from therequirement in DSM-IV (American Psychiatric Asso-ciation, 1994) that three or more behaviors be exhibitedfor CD diagnosis, whereas the delinquency severitycode is affected by severity and not number of behaviors(except for level 5 of the coding scheme, which occurredinfrequently). It could be argued that the high thresholdfor a diagnosis of CD is stringent and that the presenceof ODD is a more sensitive indicator. We did find thatpresence of either ODD or CD at baseline predictedmoderate to serious delinquency at 36 months, x21=7.03, p = .008, n = 471), but the magnitude of effect(OR 1.76) was less than that found for prediction frombaseline CD. Specifically, 32.1% (n = 86) of the 268children with ODD or CD at baseline had moderateTABLE 2Percentages of MTA and LNCG Children With Moderate to Serious Delinquency and Substance Use, Separately by SexMTA % (No.) LNCG % (No.)OR, x21,apDelinquency at 24 moBoys (N = 417 MTA, 235 LNCG)Girls (N = 107 MTA, 54 LNCG)Delinquency at 36 moBoys (N = 385 MTA, 218 LNCG)Girls (N = 102 MTA, 54 LNCG)Substance use by 24 moBoys (N = 385 MTA, 233 LNCG)Girls (N = 101 MTA, 54 LNCG)Substance use by 36 moBoys (N = 377 MTA, 216 LNCG)Girls (N = 101 MTA, 53 LNCG)20.9 (87)15.9 (17)8.5 (20)1.9 (1)2.85, 15.81, p = .00010.50, 5.04, p = .02529.6 (114)17.6 (18)8.3 (18)3.7 (2)4.51, 30.81, p = .0005.57, 4.97, p = .02612.2 (47)9.9 (10)5.2 (12)7.4 (4)2.63, 8.20, p = .0041.39, 0.28, p = .59718.6 (70)12.9 (13)7.9 (17)7.5 (4)2.53, 10.39, p = .0011.63, 0.65, p = .420Note: MTA = Multimodal Treatment Study of Children With ADHD; LNCG = local normative comparison group.aStatistics are taken from logistic regressions in which age at follow-up is statistically controlled.MTA DELINQUENCY AND SUBSTANCE USE1031J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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to serious delinquency at 36 months, whereas 52.7%(n = 39) of the 74 children with CD at baseline hadmoderate to serious delinquency at 36 months. (Notethat analysis of ODD alone is not possible because,per DSM-IV and the Diagnostic Interview Schedulefor Children diagnosing algorithm, CD diagnosistakes precedence over ODD diagnosis.)Substance Use Among the MTA and LNCG ChildrenAt 24 and 36 months, there were statisticallysignificant MTA-LNCG group differences in substanceuse, with 11.7% of the MTA children (57/486) versus5.6% of the LNCG (16/287) reporting lifetime use ofany substance by 24 months (OR 2.25, x21= 8.58; p =.003) and 17.4% of the MTA children (83/478) versus7.8% of the LNCG (21/269) reporting lifetime use by36 months (OR 2.34, Wald x21= 10.63; p = .001) aftercontrolling for age. By 36 months substances thathad been used were mostly alcohol (8.4% of MTA,2.6% of LNCG; p = .005) and cigarettes (11.1% ofMTA, 3.3% of LNCG; p = .001) with a small numberof MTA children having tried marijuana (3.0% ofMTA, 0% of LNCG). Of 40 MTA children who hadconsumed alcohol, 8 reported no alcohol in the past6 months, 17 drank once or twice, and 11 drank morefrequently (4 subjects were missing data); 18 reporteddrinks 5 or more times in their lifetime. Of 53 MTAchildren who had smoked cigarettes, 24 had smokedmorethanonceand7weresmoking1ormorecigarettesperday.Therewasstatisticallysignificantoverlapinuse:45.0% (18/40) of MTA children who had consumedalcohol had smoked a cigarette, and 34.0% (18/53) ofMTA children who had smoked a cigarette hadconsumed alcohol (x21= 33.96; p = .000). SignificantMTA-LNCG group differences in substance use wereevident for boys but not for girls (Table 2).To test whether MTA-LNCG group differences insubstanceuseoccurredaftercontrollingfordelinquency,the percentages of MTA and LNCG youths reportingsubstance use were compared within two delinquencysubgroups: those with moderate to serious delinquencyand those without moderate to serious delinquency. Foryouths with moderate to serious delinquency, MTA-LNCG group differences were not significant at 24months(23.5%vs.19.0%,respectively,Waldx21=0.09,p = .762, OR 1.21) or at 36 months (30.0% vs. 31.6%,Wald x21= 0.07, p = .793, OR 0.87). However, foryouths without moderate to serious delinquency, moreMTA than LNCG children reported substance use at24 months (8.6% vs. 4.5%, Wald x21= 3.92, p = .048,OR 1.99) and at 36 months (12.6% vs. 6.0%, Waldx21= 6.06, p = .014, OR 2.16; the latter effects werefound controlling for age).Association Between Treatment and DelinquencyThe longitudinal pattern of delinquency seriousnessfor the MTA children, estimated from the randomeffects ordinal growth model, was quadratic. This shapewas characterized by decreasing delinquency seriousnessfrom baseline to 24 months and increasing delinquencyseriousness between 24 and 36 months, mirroring theobserved data in Table 1. Although there was variabilityacross subjects in the initial level of delinquencyseriousness, there was little variability across subjectsin the rate of change (slope) in delinquency over time(p = .40 for linear change, p = .08 for quadratic change).There were no statistically significant effects at thep < .05 level of randomly assigned treatment onindividual_s rate of change in delinquency betweenbaseline and 36 months, tested either with the originalor with the alternate sets of orthogonal treatmentcontrasts (Table 3).Prescribed medication use and delinquency se-riousnesswerenotassociatedat14months(0.01[0.24];p = .98), but they were associated at 24 months (0.63[0.23]; p = .005) and at 36 months (0.62 [0.29];p = .034). Thus, children with higher delinquencyscores at 24 and 36 months were more likely to havebeen medicated for ADHD in the past year. Thesefigures are unstandardized parameter estimates similarto unstandardized regression coefficients, with SEs inbrackets, for the associations between prescriptionmedication use and delinquency seriousness. Theseresults were equivalent across the two models withdifferent orthogonal treatment contrasts.To test whether randomly assigned treatmentpredicted level of delinquency seriousness at 14months, as opposed to slope (rate of change indelinquency), the zero time score for the slope growthfactor was rescaled to the 14-month time point(Muthe ´n and Muthe ´n, 2004). No statistically signifi-cant effects of randomly assigned treatment (for theoriginal or alternate set of treatment contrasts) resultedfor this reanalysis or for rescaling the zero time scoreto the 24- and 36-month time points. Thus, withinthe delinquency growth model, randomly assignedMOLINA ET AL.1032J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

children who did not (MedMgt+CC) (j1.38 [0.60];p = .02]. This effect was no longer significant by 36months (j0.86 [0.54]; p = .11).For the same reason (i.e., potential for overlystringent test), we tested simple bivariate associationsbetween prescribed medication use and substance use.No associations were found at 24 months (p = .39) or at36 months (p = .59). Age and prescription medicationuse were not significantly associated at 24 months (r =j0.07; p = .11) or at 36 months (r = j0.04; p = .40)ruling out age as a confounder in the association (orlack thereof) between prescribed medication use andsubstance use in these analyses.Association Between Delinquency and Substance UseFrom the second growth model, delinquency atbaseline significantly predicted substance use at 24months (0.92 [0.28]; p = .00) and at 36 months (0.53[0.17]; p = .00), such that children with more seriousdelinquent behavior at baseline were more likely toreport substance use by 24 and 36 months. The lineargrowth factor for delinquency was marginally associatedwith substance use at 24 months (j4.48 [2.54]; p = .08)and at 36 months (j3.24 [1.83]; p = .08); the quadraticgrowth factor for delinquency was marginally associatedwith substance use at 24 months (5.78 [3.11]; p = .06),and significantly associated with substance use at 36months (7.55 [2.97]; p = .01). (Again, these figures areunstandardized parameter estimates and SEs are inbrackets.) The latter result suggests the possibility thatincreasing delinquency between 24 and 36 months wasassociated with an increase in substance use in the sametime period. We explored this possibility by comparingthe children whose delinquency codes increasedbetween 24 and 36 months to the children whosedelinquency codes did not increase between 24 and36 months, on initiation of substance use. Indeed,there was more substance use initiation in the former(13.9%) than in the latter (6.4%) group (x21= 6.86;p = .009, OR 2.37), supporting this interpretation.We tested baseline CD as a predictor of substance useusing logistic regressions of substance use by 24 monthsor new/continuing substance use by 36 months on CDin addition to the orthogonal treatment contrasts andsite, using missing data estimation. Baseline CDdid notpredict 24-month (0.54 [0.34]; p = .12) nor 36-month(0.56 [0.33]; p = .08) substance use. However, thepresence of ODD or CD (56.3% of MTA children)predicted 24-month substance use (0.60 [0.30]; p =.04), but not 36 months substance use (0.30 [0.27];p = .26). Reported as an odds ratio, the MTA childrenwith ODD or CD at baseline were 1.83 times morelikely to report substance use by 24 months.In summary, baseline delinquency seriousness andgrowth in delinquency seriousness predicted 24- and36-month substance use, baseline ODD or CDdiagnosis predicted 24-month but not 36-monthsubstance use, and baseline CD did not predict 24- or36-month substance use.DISCUSSIONWe found that the majority of the MTA childrenwere not seriously delinquent or were not experiment-ing prematurely with alcohol, tobacco, or illicit drugsby the 36-month assessment when most participantswere 11 to 13 years old. Nevertheless, these behaviorswere more prevalent among the MTA than LNCGchildren, with more than one fourth of the probandsevidencing moderate or serious delinquency by the36-month follow-up. The time course was quadratic:there was a significant decrease in delinquent behaviorbetween baseline and 24 months (the treatment phaseplus 10 months posttreatment) followed by an increasein delinquency between 24 and 36 months. Asimultaneous related increase in substance use from24 to 36 months suggests the need for continued studyof both behaviors into adolescence for the MTAchildren. Children who received intensive behaviortherapy (Beh+Comb) reported less substance use by 24months than the children who did not (MedMgt+CC).There were no other effects of initial treatmentassignment (MedMgt, Beh, Comb, or CC) on growthin delinquency over time, level of delinquencyseriousness posttreatment, or substance use by the 24-and 36-month follow-ups. Self-selected prescriptionmedication treatment after 14 months was positivelyrelated to delinquency seriousness: children with moreserious offenses were more likely to be medicated afterthe end of study-delivered treatment. No associationwas observed for early substance use.In a companion article in this issue by Jensen et al., itwas reported that by the 36-month follow-up (22months posttreatment) the children in the MTA couldnolongerbediscriminatedbytheiroriginalrandomizedtreatment assignments, but on average they hadMOLINA ET AL.1034J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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maintained some of the gain made by 14 months forADHD and ODD symptoms, social skills, and overallimpairment. Children in the Beh and CC groupsmaintainedtheirposttreatmentgainsto36months,andchildren in the MedMgt and Comb groups lost theirrelative posttreatment advantage but maintained gainscommensurate with those attained by Beh or CC. It wasalso reported in the companion article in this issue bySwanson et al. (2007) that the ADHD and ODDsymptom ratings for the children in the MTA wereworsethanthosefortheLNCGatthe36-monthfollow-up, which mirrors previous reports (Swanson et al.,2001). Thus, the finding herein that delinquencydecreased during the active treatment phase, yetremained significantly higher for the MTA thanLNCG children by 24 and 36 months, mirrors thegeneral findings. The percentages of MTA youths withmoderatelyseriousdelinquentbehavior(e.g., 27%at36months) were lower than reported by Loeber et al.(1998) for similar-age urban boys in Pittsburgh(42%Y54%), but they are in the literature-suggestedrange from other longitudinal studies of children withADHD. Those figures range from 25% by age 13(Weiss and Hechtman, 1993) to 44% by age 15(Barkley et al., 1990). Thus, although the majority ofthe MTA children with ADHD did not exhibitdelinquent behavior, we did see in a subset an expecteddevelopmental unfolding of earlier behavior problemsinto more serious delinquent behavior (see Loeber et al.,1991forexpectedincreasesindelinquencybetweenfirstgrade and age 14). We will be able to test in futurestudies whether persistence of ADHD and ODDsymptoms throughout treatment and posttreatment isimportant for the development of delinquency inadolescence (e.g., see Lahey et al., 2000).It is disappointing that the intensive state-of-the-artMTA treatments did not lead to a more rapiddeceleration in delinquency beyond that of CC,although this makes statistical sense given the lack ofvariability in delinquency slopes over time across thechildren in the study. Why did treatment groupassignment fail to predict absolute level of delinquencyat 14 months and thereafter, then? This is puzzlingbecause our previous analyses (Hechtman et al., 2005;TheMTACooperativeGroup,1999a)revealsignificantreductions in ODD symptoms and diagnosis as a resultof study-managed medication, and ODD symptoms/diagnosis are strongly predictive of delinquency onsetand persistence (Lahey et al., 2000; Lee and Hinshaw,2004). Theoretically, medication management shouldhave decreased delinquency through its effect on ODD.Moreover, because improving parenting effectiveness isa key ingredient in effective delinquency treatments(Patterson et al., 1992), the combination of medicationand behavior therapy should have decreased delin-quency because of its effects on negative ineffective aswellasconstructiveparenting(Wellsetal.,2000,2006).One speculation, which follows our previous report thatabouthalfofthesampleremainedsymptomaticforbothADHD and ODD symptoms (Swanson et al., 2001), isthat different psychosocial treatment packages arenecessary to effect change for those treatment-resistantchildren. These symptom-persistent children probablyoverlap with the delinquent children identified in thisarticle, all of whom may need enhanced or prolongedinterventions beyond the regimen of behavior therapyprovided in the MTA (for review, see Pelham andFabiano, in press).Significant prescription medication effects were onlyfound after 14 months (after the end of study-deliveredtreatments) and appeared to be reactive, with more self-selected medication treatment associated with moreserious delinquency. This finding parallels our resultsreported in the companion article by Jensen et al. in thisissue, in which more medication use and more specialeducational services were associated with deteriorationin ADHD symptoms. Taken together with ourcompanion paper findings that preexisting subjectcharacteristics do not explain the absence of beneficialmedication treatment effects at 36 months (Swansonet al., 2007), these findings suggest the possibility thatprolonged medication, perhaps delivered in response tochronic and serious problem behavior, may not beefficacious. Because these findings rest on observedassociations in our data rather than experimentallycontrolled use of medication long-term, our findings donot rule out the possibility that behavior would beworse without medication.Our finding of elevated substance use among theMTA children extends earlier findings of ADHD riskto a younger age than has been previously reported. Asexpected at 11 to 13 years of age, group differences wereprincipally attributable to low level but precocious useof alcohol and/or tobacco. Also as expected, substanceuse was strongly (but not completely) associated withseverity of delinquency, and it was prospectivelyMTA DELINQUENCY AND SUBSTANCE USE1035J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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predicted by delinquency seriousness (less well pre-dicted by ODD or CD diagnosis at baseline). Previousstudies finding no group differences in any lifetime useof alcohol (which includes first drink) were almostalways studies of older adolescents beyond the age of 14and up to the early 20s (Barkley et al., 1990; Hartsoughand Lambert, 1987; Molina and Pelham, 2003). Atthese older ages, light drinking is developmentallynormative and not likely to differentiate youths withADHD from those without this diagnosis. Whenheavier levels of alcohol use (e.g., frequency ofdrunkenness, alcohol-related problems) are examinedin mid- to late adolescence, ADHD/non-ADHDdifferences do emerge (Molina and Pelham, 2003;Molina et al., 2007). Previous studies have suggestedearlierages oftobacco initiationfor youths withADHD(Milberger et al., 1997; Molina and Pelham, 2003).Thus, although small numbers of MTA youths areendorsing substance use, the higher rate of this initialuse at a young age compared with classmate controlssuggests that clinical concern is warranted. Thisinterpretation follows from the well-established associa-tion between early initiation into substance use andlater problematic use of drugs and alcohol (e.g., Grantand Dawson, 1997).We did not find evidence of protective or adverseeffects of medicationtreatment for ADHD,either studydelivered or self-selected, on the initiation of substanceuse at this young age. This null finding has beenpreviously reported for roughly this age range, in theChilcoat and Breslau (1999) sample at age 11, and inthe Developmental Trends Study for boys 13 to 15years old (Burke et al., 2001). This finding does notnegate the possibility of associations either positive ornegative later in adolescence (Barkley et al., 2003;Biederman et al., 1999) or in adulthood (Barkleyet al., 2003; Pelham et al., 2005; Lambert andHartsough, 1998; Loney et al., 2002). Whether anassociation exists (protective or predisposing) remainshighly controversial and not well studied in samplessufficiently large that confounding variables can beeffectively controlled. Protective effects are presumedto occur through a reduction in risk factors contribut-ing to substance use vulnerability (e.g., reduction inADHD or ODD/CD symptoms) or a decreased needfor self-medication (Khantzian, 1997; Wilens et al.,2003) and adverse effects are presumed to occur viaprocesses such as behavioral sensitization (Lambertand Hartsough, 1998; Pelham et al., 2005) or trainingchildrentorelyondruguseasacopingstrategy(Henkeret al., 1981). Given these conflicting arguments and theaccumulating longitudinal data on the MTA childreninto adolescence, a crucial objective of this group is toexamine the extent to which ongoing psychoactivemedication treatment is associated with the furtherdevelopment of substance use and associated problemsat older ages.Children who received intensive behavior therapy(Comb+Beh) reported less substance use by 24 monthsthan the children who received intensive medicationmanagement or community care (MedMgt+CC),which suggests enduring effects of behavior therapyon an important clinical outcome 1 year after treatmentended. We can only speculate whether the effect wouldhave endured through 36 months if maintenancebehavioral treatment had been provided. It is unclearwhat variables might be accounting for this effect giventhe lack of behavior therapy effects on a select set ofoutcomes as tested with the original treatment contrastsat 24 months (The MTA Cooperative Group, 2004a).Nevertheless, this result is encouraging, and it suggeststhe importance of continued investigation into therange of variables that may propel escalation ormaintenance of substance use (for review, see Chassinet al., 2004; Kandel and Yamaguchi, 2002). Followingthis line of thinking, it will be important in futurestudies to test the wide range of intraindividualdifference variables (e.g., ADHD and ODD symptomseverity and persistence, cognitive variables, socialskills), family factors (e.g., parental substance abuseand antisociality, parenting effectiveness), and socio-environmental variables (e.g., peer and sibling behaviorand substance use, neighborhood influences) that, inaddition to treatment and conduct problems, mayaffect the initiation and course of substance use in theMTA children.LimitationsFirst, although generalizability of these multisitefindings should be better than from single-site studies,it is important to recall that participants were requiredto have Combined type ADHD. Thus, conclusionsmay not be generalizable to the Inattentive subtype ofADHD, which may be qualitatively different (Milichet al., 2001). Second, our measure of delinquencyseriousness is an improvement over simple countMOLINA ET AL.1036J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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variables (e.g., adding up the number of disparatebehaviors endorsed), but we cannot rule out thepossibility that different results would emerge fromalternative scoring algorithms. Third, the young age ofour sample may have precluded detection of differentialtreatment effects on delinquency. Greater variability inthis outcome appears to be emerging at older ages.Although even more delayed effects of treatment ondelinquency are not expected, further study of thesample into adolescence will allow more finely grainedanalyses of the simultaneous development of specificdelinquent behaviors and substance use. Finally, animportant caveat regarding our ability to test effects ofongoing (self-selected) treatment was our considerationof only prescribed medication treatment and notpsychosocial treatments; the latter are difficult tostudy because of measurement challenges.Clinical ImplicationsMost of the MTA children were not engaging indelinquent behaviors or experimenting with alcohol,tobacco, or other illicit drugs by 11 to 13 years of age.However, our finding that the MTA children were atincreased risk of delinquency and early substance use 2years after intensive pharmacological and/or behavioraltreatment underscores the need for continuous mon-itoring of these outcomes as the children enteradolescence. Parents of children with ADHD shouldbe informed about this risk, and strategies to improveparental monitoring (Chilcoat and Breslau, 1999;Molina et al., 2005) and minimize negative peerinfluences (Marshal et al., 2003) implemented.The Multimodal Treatment Study of Children with ADHD(MTA) was a National Institute of Mental health (NIMH)cooperative agreement randomized clinical trial involving sixclinical sites. Collaborators from the National Institute of MentalHealth: Peter S. Jensen, M.D. (currently at Columbia University,New York), L. Eugene Arnold, M.D., M.Ed. (currently at OhioState University), Joanne B. Severe, M.S. (Clinical Trials Opera-tions and Biostatistics Unit, Division of Services and InterventionResearch), Benedetto Vitiello, M.D. (Child & Adolescent Treat-ment and Preventive Interventions Research Branch), KimberlyHoagwood, Ph.D. (currently at Columbia University); previouscontributors from NIMH to the early phase: John Richters, Ph.D.(currently at National Institute of Nursing Research); DonaldVereen, M.D. (currently at National Institute on Drug Abuse).Principal investigators and co-investigators from the clinical sites areUniversity of California, Berkeley/San Francisco: Stephen P.Hinshaw, Ph.D. (Berkeley), Glen R. Elliott, M.D., Ph.D. (SanFrancisco); Duke University: C. Keith Conners, Ph.D., Karen C.Wells, Ph.D., John March, M.D., M.P.H., Jeffery Epstein, Ph.D.;University of California, Irvine/Los Angeles: James Swanson, Ph.D.(Irvine), Dennis P. Cantwell, M.D. (deceased, Los Angeles),Timothy Wigal, Ph.D. (Irvine); Long Island Jewish MedicalCenter/Montreal Children_s Hospital: Howard B. Abikoff, Ph.D.(currently at New York University School of Medicine), LilyHechtman, M.D. (McGill University, Montreal); New York StatePsychiatric Institute/Columbia University/Mount Sinai MedicalCenter, New York: Laurence L. Greenhill, M.D. (ColumbiaUniversity), Jeffrey H. Newcorn, M.D. (Mount Sinai School ofMedicine); University of Pittsburgh: William E. Pelham, Ph.D.(currently at State University of New York, Buffalo), Betsy Hoza,Ph.D. (currently at University of Vermont, Burlington), BrookeMolina, Ph.D. Original statistical and trial design consultant:Helena C. Kraemer, Ph.D. (Stanford University). Follow-up phasestatistical collaborators: Robert D. Gibbons, Ph.D. (University ofIllinois, Chicago), Sue Marcus, Ph.D. (Mt. Sinai School ofMedicine), Kwan Hur, Ph.D. (University of Illinois, Chicago).Kate Flory, Ph.D. (University of South Carolina at Columbia).Andrew Greiner, B.S. (State University of New York at Buffalo).Collaborator from the Office of Special Education Programs/U.S.Department of Education: Thomas Hanley, Ed.D. Collaboratorfrom Office of Juvenile Justice and Delinquency Prevention/Department of Justice: Karen Stern, Ph.D.Disclosure: During the course of the MTA, since 1992: Dr. Hinshawhas consulted to Noven and Sigma Tau and has been on the speakers_bureau of McNeil. Mr. Greiner has consulted to ComprehensiveTreatment for ADHD, Inc., the Research Foundation of the StateUniversity of New York, and the Clinical Trials Coordination Centerof the University of Rochester Medical Center. Dr. Arnold has receivedresearch funding from Celgene, Shire, Noven, Eli Lilly, Targacept,Sigma Tau, and Novartis; has consulted to Shire, Noven, Sigma Tau,Ross, and Organon; and has been on the speakers_ bureaus of Abbott,Shire, McNeil, and Novartis. Dr. Swanson has received researchsupport from Alza, Richwood, Shire, Celgene, Novartis, Celltech,Gliatech, Cephalon, Watson, CIBA, Janssen, and McNeil; has been onthe advisory boards of Alza, Richwood, Shire, Celgene, Novartis,Celltech, UCB, Gliatech, Cephalon, McNeil, and Eli Lilly; has been onthe speakers_ bureaus of Alza, Shire, Novartis, Celltech, UCB,Cephalon, CIBA, Janssen, and McNeil; and has consulted to Alza,Richwood, Shire, Celgene, Novartis, Celltech, UCB, Gliatech,Cephalon, Watson, CIBA, Janssen, McNeil, and Eli Lilly. Dr.Hechtman has received research funding from the National Institute ofMental Health, Eli Lilly, GlaxoSmithKline, Janssen-Ortho, PurduePharma, and Shire; has been on the speakers_ bureaus of the NationalInstitute of Mental Health, Eli Lilly, Janssen-Ortho, and Shire; and hasbeen on the advisory boards of Eli Lilly, Janssen-Ortho, PurduePharma, and Shire. Dr. Jensen has received research funding fromMcNeil and unrestricted grants from Pfizer; has consulted to BestPractice, Inc., Shire, Janssen, Novartis, and UCB; and has participatedon the speakers_ bureaus of Janssen-Ortho, Alza, McNeil, UCB, CMEOutfitters, and the Neuroscience Education Institute. Dr. Vitiello hasconsulted to Richwood Pharmaceuticals. Dr. Hoza has received researchfunding from MediaBalance, Inc. and support for educationalconferences from Abbott Laboratories. Dr. Pelham has received researchfunding from Alza, Shire, Noven, Eli Lilly, and Cephalon; has servedon advisory boards of or has consulted to Alza/McNeil Richwood/Shire,Noven, Eli Lilly, Cephalon, Novartis, Celgene, and Abbott; and hasbeen on the speakers_ bureaus of Shire, and McNeil. Dr. Elliott hasreceived research funding from Cephalon, McNeil, Shire, Sigma Tau,MTA DELINQUENCY AND SUBSTANCE USE1037J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007

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"However, it is unknown whether inconsistent discipline is more common among parents of adolescents with ADHD histories. There is recent promising evidence that behavior therapy for childhood ADHD, which included parent training, leads to lower rates of experimentation with substances in early adolescence (Molina et al., 2007). These findings suggest that parental discipline consistency in adolescence may also have important implications for the management of delinquency and substance use for adolescents with ADHD histories . "

[Show abstract][Hide abstract]ABSTRACT: Several domains of parenting have been identified as important for adolescent well-being. Whether these same domains are equally beneficial for adolescents with ADHD histories remains an empirical and clinically important question. This study examined whether parental knowledge of their teen's activities and whereabouts, consistency, support, and parent-adolescent conflict are associated with substance use and delinquency similarly for adolescents with and without a diagnosis of ADHD in childhood. A sample of 242 adolescents, 142 diagnosed with ADHD in childhood and prospectively followed into adolescence, and 100 without ADHD in childhood, were the focus of study. The relations between adolescent-reported outcomes (i.e., substance use and delinquency) and parenting behaviors were tested using latent variable modeling to determine both the effects of general (common) and specific (unique) parenting behaviors for participants with and without a history of ADHD. Adolescents' report of parental knowledge was a significant correlate of delinquency and substance use above and beyond other parenting variables and the variance in common across the parenting variables. More knowledge was associated with less delinquency and substance use for all participants, but parental knowledge was more strongly associated with alcohol use for adolescents with versus without childhood ADHD. These correlational findings suggest that, despite the increased difficulty of parenting youths with ADHD histories, actions taken by parents and youth to increase parental awareness may provide some protection against behavioral transgressions known to be elevated in this population. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

"ns, but highest parent education was lower in the proband than in the comparison group, ␹ 2 ͑5͒ ϭ 13.989, p Ͻ .05. Younger teens were excluded due to their smaller numbers and low rates of drinking (Molina, Pelham, et al., 2007); 18 year olds were excluded because of the associated educational and residential transitions at that age that have implications for alcohol consumption . Driven by our hypotheses about rate of increase in alcohol consumption with age, we modeled alcohol use by age rather than by year of the annual interview as recommended when age varies considerably within the sample in a given year or " wave " (Bollen & Curran, 2006). "

[Show abstract][Hide abstract]ABSTRACT: Research on the relation between childhood attention-deficit/hyperactivity disorder (ADHD) and adolescent alcohol use has found mixed results. Studies are needed that operationalize alcohol use in developmentally appropriate ways and that test theoretically plausible moderators and mediators in a longitudinal framework. The current study tested childhood ADHD as a predictor of alcohol use frequency at age 17 and age-related increases in alcohol use frequency, through adolescence for 163 adolescents with ADHD diagnosed in childhood and 120 adolescents without ADHD histories. Childhood ADHD did not predict either alcohol outcome. However, parental knowledge of the teen's friendships, activities, and whereabouts moderated the association such that childhood ADHD predicted alcohol use frequency at age 17 when parental knowledge was below median levels for the sample. Mediational pathways that explained this risk included social impairment, persistence of ADHD symptoms, grade point average, and delinquency. Social impairment was positively associated with alcohol use frequency through delinquency; it was negatively associated with alcohol use frequency as a direct effect independent of delinquency. These nuanced moderated-mediation findings help to explain previously inconsistent results for the ADHD-adolescent alcohol use association. The findings also imply that future research and intervention efforts should focus on ADHD-related social and academic impairments as well as symptom persistence and parenting efforts. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

"In addition to its association with cognitive functioning and school performance (NICHD Early Child Care Research Network, 2005), deficits in sustained attention are also predictive of worse social outcomes (Andrade, Brodeur, Waschbush, Stewart, & McGee, 2009; Murphy, Laurie-Rose, Brinkman, & McNamara, 2007). Deficits in childhood sustained attention abilities also appear to be chronic in nature as they have been found to be associated with similar attentional deficits in adolescents and adulthood (Biederman et al., 1998; 2007) and similar negative consequences including risky health behaviors, social deficits, and occupational impairments (Barkley, 2002; Fischer, Barkley, Smallish, & Fletcher, 2007; Molina et al., 2007). "

[Show abstract][Hide abstract]ABSTRACT: The current study examined the role of maternal behavior and toddlers' emotion regulation strategies in the development of children's sustained attention abilities. Participants for this study included 447 children (232 girls) obtained from three different cohorts participating in a larger ongoing longitudinal study. When the children were 2 years of age, mothers brought their children to the laboratory and were videotaped during several tasks designed to elicit emotion regulation and mother- child interaction. Sustained attention was also measured at the same visit via a laboratory task and in a subsequent visit when children were 4.5 years of age. Results indicated that toddlers' use of help-seeking emotion regulation strategies was positively related to sustained attention while avoidance behaviors and maternal behavior characterized by high levels of overcontrolling/intrusiveness were negatively related to sustained attention at age 2. Significant interactions emerged such that high levels of maternal warmth/responsiveness buffered the negative associations between low use of distraction and high use of self-comforting emotion regulation strategies and sustained attention at age 2. Maternal behavior characterized by high levels of warmth/responsiveness also predicted greater growth in sustained attention from age 2 to 4.5. These findings are discussed in terms of how maternal behaviors and children's use of active versus passive emotion regulation strategies relate to sustained attention abilities.